A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?

Placing a sign on the client's room door indicating fall risk.

b. Encouraging the client to use the call bell for assistance.

Providing a nonskid mat on the floor beside the client's bed.

Ensuring the client has adequate lighting in the room.

Answer and Explanation

The Correct Answer is B

nswer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.

Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.

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Correct Answer is A

Explanation

The correct answer is choice A. Jitteriness.Jitteriness or tremors are the most common signs of hypoglycemia in a newborn baby.

Hypoglycemia is when the level of sugar (glucose) in the blood is too low.

Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can happen for many reasons, such as poor nutrition for the mother during pregnancy, making too much insulin because the mother has diabetes, or not enough oxygen at birth.

Choice B. Tachycardia is wrong because it is not a typical sign of hypoglycemia in a newborn baby.

Tachycardia is a fast heart rate that can be caused by other conditions, such as fever, infection, or dehydration.

Choice C. Hyperthermia is wrong because it is not a sign of hypoglycemia in a newborn baby.

Hyperthermia is a high body temperature that can be caused by overheating, infection, or inflammation.Hypoglycemia can cause low body temperature (hypothermia), not high body temperature.

Choice D. Hypertonia is wrong because it is not a sign of hypoglycemia in a newborn baby.

Hypertonia is increased muscle tone or stiffness that can be caused by brain damage, nerve damage, or genetic disorders.Hypoglycemia can cause weak or floppy muscles (poor muscle tone), not increased muscle tone.

A. To prevent infection B. To increase blood flow C. To reduce pain D. To prevent bruising

Correct Answer is B

Explanation

The correct answer is choice B. To increase blood flow.A heel warmer is applied to the newborn’s foot before obtaining the blood sample to increase the blood flow to the area and make it easier to collect the sample.A heel warmer can also reduce pain and bruising by dilating the blood vessels and reducing the need for multiple punctures.

Choice A is wrong because a heel warmer does not prevent infection.Infection prevention requires proper cleaning of the puncture site and disposal of the lancet.

Choice C is wrong because a heel warmer does not reduce pain by itself.Pain reduction requires other measures such as cuddling, feeding, and distraction.

Choice D is wrong because a heel warmer does not prevent bruising.Bruising prevention requires applying pressure to the puncture site after collecting the sample.

Normal ranges for blood glucose levels in newborns vary depending on the method of measurement, but generally they are between 2.6 and 6.0 mmol/L.

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A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who was born to a mother with diabetes mellitus. The nurse should monitor the newborn for which of the following signs of hypoglycemia?

Correct Answer is A

Explanation

A nurse is performing a heel stick blood glucose test on a newborn who is preterm. The nurse should apply a heel warmer to the newborn’s foot before obtaining the blood sample for which of the following reasons?

Correct Answer is B

Explanation

Which data would be included in a health history? (Select all that apply.)

The diagnosis of pregnancy is based on which positive signs of pregnancy? (Select all that apply.)

A client with diabetes gives birth to a premature newborn. The nurse should anticipate that the newborn is at risk for:.

A nurse is reviewing the laboratory results of a pregnant client. Which finding would be considered abnormal regarding hCG levels?

A nurse is teaching a pregnant client about nutrition during pregnancy and lactation. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a newborn who has intrauterine growth restriction (IUGR). The nurse should recognize that this newborn is at risk for developing hypoglycemia because of which of the following factors?

A nurse is assessing a newborn who is displaying jitteriness, poor feeding, and seizures. The nurse suspects the newborn is experiencing:.

The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately?(Select all that apply.).